MAYDAY IN THE MAGELLAN – PART III What Caused the Flood?

Ten years ago, the Royal Navy’s Ice Patrol Vessel HMS Endurance catastrophically flooded. Her main engine room filled to the deckhead within 30 minutes. Such was our remoteness our Mayday call went unanswered. The crew and I spent the next 24 hours fighting for our lives.

This article is the final part of a three-part blog focusing on leadership, culture and priorities. Part 1 – Leadership was published in December and can be found here. Part II – Priorities is here. Part III – Culture, looks at what caused the flood and was it inevitable or could more have been done to prevent it? What was it about the ship that set it apart and yet rendered it so flawed? Has the Royal Navy learned the lessons from this incident?

Part III – Culture

Introduction

Joseph Nye in
his paper Inevitability and War argues that conflict occurs only
when three causal thresholds have been crossed; deep, intermediate and
precipitating. His analogy is that of building a fire: “The logs are the deep cause, the
kindling and paper are the intermediate cause, and the striking of the match is
the precipitating cause.”

By looking at
the causes of the flood through these lenses it is hoped that this blog will
broaden the findings of the relevant Service Inquiry which tended towards the more
precipitating events. These are naturally woollier and more open to
interpretation and thus perhaps the reason the Service Inquiry avoided them. My
aim here is not to expose or embarrass anyone, but to inform those who are
interested in this subject (and there are many). If it helps those currently
responsible for running the replacement ship HMS Protector, then so much the
better. And if I do raise concerns about the culture onboard prior to the flood,
then that must be set against the fact that it was exactly the same culture
that so heroically saved the ship as described in Part 1.

Deep Causes (1990 – 2008)

This
section covers the 18 year period from purchase-to-incident during which the
way the ship was manned, operated and assured all diverged from her design
criteria.

The Royal Navy’s Antarctic Survey Vessel HMS Endurance during her patrol of the Antarctic Peninsula early in 2007.

People.

MV Polar Circle was designed to have a crew of 38. By the time she became HMS Endurance, she had a complement of 119. It’s not entirely clear why. Merchant vessels generally run with very lean crews when compared to their Royal Navy counterparts for a number of reasons; they are mechanically simpler, they don’t need large numbers of people for battle damage repair, and their equipment and staffing is designed to minimize crew costs. As one would expect, putting 119 people in a ship designed to run with 38 and only occasionally surge to higher numbers put considerable and sustained strain on her systems.

Operations.

MV Polar Circle was built to operate in the Arctic, a relatively short hop from its home port, and to undergo dry-docked maintenance once a year. HMS Endurance operated every austral summer in the Antarctic—a harsher environment, requiring a much longer commute. This had consequences both serious and comical: the heated shower floors, whilst lovely in Antarctica, made a lot less sense off the West Coast of Africa, and couldn’t be turned off. More seriously, crossing the equator with no air conditioning (which Endurance had to do twice yearly) caused regular engineering issues. Most seriously of all, under naval ownership she was dry-docked and refitted only every five years – far beyond her design criteria. Her last docking period, in Falmouth in 2004/5, was generally reckoned to have been a disaster. More on that later.

There
is a phrase in common usage amongst warship drivers: “drive it like you stole
it”. It alludes to a sort of Bondian derring-do; cavalier yet sharp –
understand the limits of your ship and then vigorously explore them. Sensibly
applied to an agile, high-powered warship fitted with systems expecting to be
stressed, it’s a good thing. Where it doesn’t work at all is in a large, heavy,
relatively underpowered ice-breaker whose machinery is designed to be run for
very long periods without excessive loading or alterations. As an example,
Endurance had a propulsion configuration called “ice-mode” that directed all
power away from non-essential systems through the single shaft in order to
optimise her performance in the ice. Not only did it sound cool, it gave you
nearly a whole extra knot of top
speed. So, of course, the ship had steamed around in ice-mode at full throttle
for years. There’s a reason Endurance was nicknamed The Big Red Plum and it
wasn’t because of her raked bow, slender lines or wave-piercing prowess –
“drive it like you want it to run forever” would have been more sensible.

In
every warship in the fleet, breakdown drills are conducted routinely three
times a week as an essential part of ensuring that everyone onboard
instinctively knows the systems and their reversionary modes. Continuing to
provide propulsion to a warship under fire is clearly a core skill, so we did breakdown
drills routinely…but we weren’t a warship. A Bergen shipping engineer visited
us off Africa after a particularly unreliable passage and discovered that every
drill we conducted was damaging the engine control systems: we were starting
each serial when the mechanics had reset from the previous drill but,
unbeknownst to everyone, the electrical control systems had not; this had been
going on for 20 years. The Bergen engineer was a vocal man, or he may have just
had a loud voice, but when he shouted at me “would you do these drills in the
ice in Antarctica?” and I answered “no” he bellowed, “SO WHY ARE YOU DOING THEM
NOW?” My answer “because they support career progression and conform to Fleet
Engineering Orders” felt pretty lame.

Assurance.

Integrated Project Teams(IPTs) were part of Naval engineering standards and assurance for many years, normally with a high degree of success. However, it was clear by 2005 that the Minor Warships and Boats IPT (MWAB), of which Endurance was a major element, was not fit for task and thus the Minor, Patrol and Hydrography IPT (MPHIPT) was born. I have received written accounts from engineers who served in Endurance over this period and their assessments of the new group are scathing. The ship was in a constant state of materiel fragility almost across the board. Our Operational Defect list was excessively long and measures were never in place to take the required bold action to fix it.

Between
the IPT and the ship’s captain there are two Naval organisations responsible
for delivering ships on operations: Flag Officer Sea Training (FOST) and the
Flotilla organisation, in our case in Portsmouth Dockyard. Neither were
familiar with Endurance or her systems. Their training and inspection
methodologies were all configured for grey ships – very few understood the red
one. Admittedly, this was compounded over the years by senior ship’s companies
(and Commanding Officers) holding these organisations at arms-length on the
principle that “we know how to operate our ship – you don’t”. When a ‘wrecker’
(a member of the FOST team responsible for simulating damage in order to train
your teams in controlling it) admits that they’re “making it up as they go
along when they inspect Endurance” then you know something is wrong.

The
ship was formally assessed by a small FOST team a couple of months prior to the
incident. In isolation there are some telling comments in their final report:

“Equipment. Despite the best efforts of the engineering department, the equipment is assessed as “below standard” due to the defects on both shaft generators. There are an additional five outstanding high-level defects.”

“Sustainability. The Main focus of the forthcoming period will be defect rectification…”

But
the overall impression of the report was one of “doing OK considering. Nothing
fantastic, plenty of caveats, but nothing to worry about.” Of course, all we
wanted to do at the time was get rid of the inspection teams and get back to
sea.

Culture.

There were two things wrong with the culture in HMS Endurance – “this is the way we’ve always done it” and alcohol consumption. Both of these, anecdotally but believably, predate the ship and perhaps go all the way back to the first HMS Protector, but certainly existed in the previous HMS Endurance. The stories of mishap in these two ships are legion and worn almost as a badge of pride in various blogs and groups.

Prior
to taking over as second in command of Endurance I attended an eight-week
course to prepare me. This is a standard RN course that refreshes you on all manner
of things from your knowledge of the Rules of the Road, to the power and
propulsion systems in your upcoming ship, to the latest regulations for dealing
with errant sailors. I have never been asked to stay behind after lectures “for
a chat” so much in my life. Every time it was to give me examples where standards
of maintenance and discipline onboard were of concern. Individually I treated
the stories with caution – ‘dits’ like that often magnify in the telling. Collectively,
it was clear that there was a problem but I didn’t want to pre-judge too much –
and how bad could it really be? Either way, I joined with my eyes and mind open.

Imagine
my surprise when I joined to find everyone wearing slippers around the ship.
It’s quite hard to describe how inappropriate and unsafe—and simply odd—this is
to someone not used to operating in warships and therefore how comprehensively
that image encapsulates “The Endurance Way” and all that was wrong with it. I
had an exceptional Executive Warrant Officer who was also new to the ship and
who had been equally well pre-briefed. One of my early conversations with him
was over slipper-gate and what we should do about it. He was also opposed so I
suggested that we ban slippers immediately, only to find that it was permitted
in Ship’s Standing Orders! Ignoring the advice given on my course to not go in
too hard too early, we banned them anyway. A unique ship operating in the most
hostile conditions on the planet is bound to diverge from the norm a little,
and a bit of character is a good thing. The key, and what often seemed to be
missing in Endurance, is knowing where and how.

Drink culture was hardwired into Endurance, more than
any other ship I served in. This was principally because the senior ratings who
would normally set the tone for this kind of thing were often in their last
tour and many harked back to some sort of misplaced notion of ‘the good old
days’. Again, this was a common feature across the entire ship’s lifespan and
was probably even brought across from the previous Endurance. The fact that she
wasn’t a warship per se, certainly lent itself to a more relaxed and informal
atmosphere that in turn lead to too much drinking whilst at sea. Tighter
control mechanisms were put in place by the Captain and I and the first person
to contravene them spent 28 days in Colchester’s service prison. Many
conversations took place discussing the dates that the worst offenders were due
to leave and how they could be accelerated. All sensible measures. However, with
the wisdom of hindsight, maybe we didn’t do enough.

To summarise
the Deep Causes, since 1990, the Royal Navy had been operating the ship
contrary to its design criteria. This caused her to age prematurely and the
assurance mechanisms were not robust enough to halt the decline. Then, the
“Endurance Way” was often misplaced leading to lower standards in many areas.

Intermediate Causes (2005 – 2008)

This section takes us from the refit in Falmouth in 2005 to the flood.

18 Month Deployment.

At the top of the list of intermediate causes was the plan to deploy for 18 months. The then Commander in Chief was, not unreasonably, looking at ways to get more out of the fleet. Endurance’s operating cycle was pretty inefficient, so the notion of keeping her ‘down south’ for an austral winter, rather than transiting c8500 miles back to and from the UK each time, was a good one. The ship would conduct multiple Work Periods in the ice then, as the austral winter set in, head for the ex-Naval dockyard of Simon’s Town, South Africa for her mid-deployment maintenance. From there, she would conduct a period of engagement up the coast of West Africa before returning to the Falklands and then Antarctica for the start of the following austral summer. So far, so good. However, there were two major omissions from the plan. First, no consideration was given to what deploying for this length of time would do to an already fragile platform. Second, with no extra crew assigned, the agreed rotation involved sending one third of the ship’s company home at any given time. This became known as ‘managed gapping’ and was just as chaotic and disruptive as the name implies.

My statement
above that Endurance was over-staffed remains true. However, ‘managed gapping’
one third of the crew also meant that the ship was now under-staffed in
the sense that the resident expert on any given system might be gone one-third
of the time. We had too many bodies overall and yet not enough specialists for
key systems. An odd dichotomy. On the day of the flood, the person responsible
for the equipment that failed was on leave and whilst his advice was sought by
e-mail, the reply (which was “don’t do the work”) came too late to be heeded.

Nothing in the
pre-deployment documentation suggests that any of this tautness was challenged
and thus we fell foul of a classic case of press-on-itis. Someone between the
ship and the Commander-in-Chief should have challenged the way the deployment
was configured and the associated cumulative risk associated with deploying a
clearly fragile ship for this length of time. The Marine Accident Investigation
Branch (MAIB) call this a failure of organizational
influence:

“Organizational influence is a two-way exchange: Organizations cannot accomplish their goals if they can’t influence their members to do the right things. And the members, of course, cannot do the right things—and satisfy their needs in the process—if they can’t influence what goes on in their organizations.”

Refit.

In 2004 the ship went into its five-yearly refit in Falmouth. Speaking to uniformed personnel who were onboard either during or just after reveals that this was a substandard refit. On undocking the ship’s stability condition was so poor that she rolled to 45 degrees and had to be quickly bullied back onto the blocks and errant water pumped out – this seemed to set the tone. All defects are logged onboard through a process called OPDEF (Operational Defects) reporting. I have it on good authority that the OPDEF count post 2005 was significantly higher than before and anecdotally, that she never felt the same. It was during this refit that the actuator at the heart of the incident was replaced with a non-compliant valve actuator, such that the actuator air-lines had to be disconnected to remove the sea suction strainer lid. More on that later but this was indicative of the poor standards of workmanship undertaken and accepted during that period.

Engineering Standards.

There is no nice way of saying this. The end result of much of the above was a ship with poor engineering standards. I was supposed to join her in Cape Town but had to divert to the Falklands because on sailing to transit the South Atlantic, and before having left sheltered waters, her shaft bearing seized locking the (only) propeller firmly in position. It turned out that the person whose job it was to check the oil level in the bearing prior to sailing hadn’t bothered. This was a pivotal moment in the story because when I eventually joined, I found that the legal advice from ashore on how to deal with this incident involved sacking a large percentage of the team. The problem with that, and the discussions I had at length with the Captain, was who would replace them? We still had well over a year to run in this deployment and the only RN expertise in the platform was already onboard. In the end we both agreed that the most sensible course of action was to manage the situation we had. But that was only one incident. On sailing from the Falklands again, pipework to the roll reduction tank ruptured and dumped seven tons of water into the engine room causing significant secondary damage. On another occasion, a tank was overfilled, warping the lid and again, flooding the engine room – this was becoming a habit. We eventually made it to South Africa and received our maintenance package, but on sailing into the tropical waters of West Africa it was clear that all was not well as propulsion system failings caused the ship to regularly end up dead in the water.

The
Intermediate causes were succinctly summed up in the Service Inquiry:

“Externally, the provision of engineering and management assurance for a unit conducting an unusually lengthy deployment in a remote and challenging environment was insufficient, and the significance of previous incidents suggesting poor engineering management were not recognised.”

Precipitating Causes (7 days leading up to
the flood)

So, who did
what on the day and immediately prior to the flood? This in some ways is the
easiest section to review as the Service Inquiry covers it in detail.

Since leaving
South Georgia we had been struggling to produce enough fresh water for the very
high number of people on board. However, this was far from critical and we had
options for managing it that had yet to be put in place. The order/threat given
to the senior engineers that morning, “improve fresh water production or we’re
going to the Falklands for Christmas” was therefore clumsy and certainly
contravened the Command Aim of “safe passage to Valparaiso”. It also set in
train a rather hurried and poorly diagnosed piece of work. As mentioned
previously, the ‘owner’ of the valve in question was contacted and advised by
return e-mail against doing the work at sea, but the advice was not heeded or
even seen.

No risk
analysis was conducted prior to commencing the work, nor was there a fixed
procedure in place for such a thing. Neither the Engineer nor I knew that we
were going to be ‘one valve open to the sea’ whilst the work was going on. In
the US Navy, a ship to be in this condition requires sign-off from the captain.
Given the sea-state, our relative proximity to Valparaiso and the fact that we
were at flying stations, I’m not sure I’d have given it; easy to say now mind.

What happened
next is summarized in the Service Inquiry:

“The opening of the hull valve was caused by the incorrect re-connection of the air control lines during the reassembly of the strainer, and a failure to fully isolate the compressed air supply to those lines. There were a number of contributory factors: poor system knowledge among those attempting the maintenance work; the absence of the appropriately trained system maintainer due to the manpower constraints of an extended deployment; management failure to implement a safe system of work including adequate risk assessment and mitigation measures; a failure to apply satisfactory engineering practice and design shortfalls in the valve control system.”

What was not
clear then, and never will be, was whether the “failure to fully isolate the
compressed air supply to those lines” was due to a defective valve upstream in
the system (i.e. it was passing air despite having been closed properly) or
human error (i.e. that valve was opened prematurely before the main valve lid
had been re-secured). The Technical Investigation suggested the former but the
Service Inquiry suggested the latter. By the time the Service Police came along
to investigate almost a year after the event (and they were the first team who
had the remit to apportion blame) the evidence had been long since contaminated.
Because of this, no one person was ever blamed for the incident. I’m glad about
this. One of the points of this article is to indicate the breadth and depth of
causal issues and therefore if at the end of the investigation one person had been
held responsible, then that would have been unfair.

I will at this
point defend the Engineer who came under considerable scrutiny during the
endless investigations (see Part 2). When it became clear that proving ‘who
did what to which valve’ was going to be impossible then the broader business
of engineering culture started to be questioned. As highlighted above, this would
have been reasonable had it been spread over an appropriate timeline. However,
pinning it on the person who had taken charge of the department just 17 days
before, was not. He subsequently won a formal letter of guidance from the
Admiralty that, in my view, he hadn’t earned. It also, and this is inevitable
I’m afraid, cancelled out his impeccable performance as the head of the damage
control organization during the flood itself.

The Ice Patrol Ship, HMS Endurance on board the Heavy Lift ship, Target in Stokes Bay after her piggy back ride from the South Atlantic where she was very nearly lost. Photo courtesy of and all rights reserved by Steve Wright [https://www.flickr.com/photos/jacksonphreak/]

Administrative action

After all was
said and done, the Navy took very little administrative action. Technically and
legally unable to pin the blame on an individual, and seemingly unwilling to
dig into the deeper causes, the end result was a handful of ‘letters of
guidance’ to various members of the engineering department. Outside of the
ship, where many of the causal issues lay, no action was taken.

Lessons

Having said
that, much was learned from this incident that has since been transferred into
the wider Royal Navy. The service from the Fleet Incident Response Cell was
outstanding that day and that system is now firmly in place for future major
incidents. The relationship between ships and their many external auditing
agencies is now smarter than it was which is good news especially given how ships
are getting more complex, living longer than their designed lives and operating
in an increasingly resource constrained environment. Damage control lessons
have been taken to the school in Whale Island and are routinely taught to
ships’ crews as they pass through. However…

HMS Protector

In
2009, about nine months after the flood, I went to sea for a day in MV Polar
Bjorn to scope her out as a possible replacement ice breaker as the prohibitive
cost of repairing Endurance was starting to become clear. It was a very
interesting day, not least of which was because she had a crew of just 17.
That is an unremarkable number for a merchant vessel but is almost unimaginably
low to those used to operating RN ships. (For example, a ‘lean-manned’ Type 23
Frigate deploys with over 200 crew). Polar Bjorn’s engineering department had just
seven people in it. She operated a two-crew system on a five-week rotation
so successfully that she lost only 18 hours on-task over seven and a half years
due to defect rectification. Their system knowledge, ability to order stores
quickly and conduct repairs at sea whilst still on task left me and the
visiting engineer from Abbey Wood both deeply impressed and scratching our
heads. We were clear that if we were to procure Polar Bjorn to replace
Endurance then we should adopt a similar operating model even if this meant deviating from ‘normal’
RN practice.

Protector is
now firmly in service and has been operating in the deep south now for some
time. My suggestion to mimic her previous operating methodology and create a
lean two crew system of about 30 per crew (there was no-way we could manage 17
by the time the Hydrographers and Royal Marines were added) was very quickly
ignored, as were my thoughts on the shape and seniority of the engineering
department. In fact, she currently has a crew of about 80 operating on a
three-watch rotation. Sound familiar? As for other cultural habits that we
inherited all those years ago, I am not well placed to judge if we passed any
of them on. I do hope that if the notion of “the Protector way” exists onboard,
then it is being applied for the right reasons.

As an aside,
but for the Foreign Office’s requirement to keep a White Ensign flying in the
Southern Ocean, I believe this task would have been handed to the Blue Ensign
of the Royal Fleet Auxiliary whose natural tendency to lean-crew ships would
have made them a most suitable operator.

Conclusion

To conclude, two
questions should be addressed; was the flood inevitable and could we have done
more to prevent it?

To answer the
first, I don’t think it was inevitable. Since Parts 1 and 2 of this blog were
published I’ve had a handful of Endurance ship’s company contact me with
stories that could make you think it was. Certainly, when all the woes are
compressed in a blog like this you can convince yourself that it was. However,
this kind of dit-compression (as I’m now calling it) is misleading. In reality,
the gaps between incidents were much longer than the incidents themselves and
we did have a knack of muddling through them, making it to the next work period
or port on time and always with a healthy post-operational report to submit to
the Admiralty. If
someone in authority had confronted the larger issues effectively and sooner,
and thereby broken the chain leading to the precipitating error, I am convinced
that the flood could have been averted.

So why didn’t
we do more onboard to see and prevent this happening? Partly because it’s
hard-wired into every naval commanding officer to go to sea and, if necessary,
bring violence to the enemy. Staying alongside because you think your ship
might not be safe is utterly contrary to RN norms and values and would most likely
end with you being replaced by someone who would. Ruling out that path—not even
considering it seriously—left us on the much less effective path of attempting
major repairs-in-place on the ship’s culture and practices while also
conducting operations. Both the Captains I served with in Endurance, the
Executive Warrant Officer and I spent hours every day discussing how we should
tackle both the culture and the poor engineering standards and we had plans in
place that reflected the nature of the deployment that we were on and the
people involved. Regrettably, they weren’t enough, or at least they weren’t in
time. But here is the rub: the chain
should have been broken long before we ever left Portsmouth. B.M. Batalden
& A.K. Sydnes’s conference paper, “What causes ‘very serious’ maritime
accidents?” written in 2017 summarizes the nature of the most serious failings
perfectly:

“The study
builds on investigation reports published by the UK’s Marine Accident
Investigation Branch (MAIB) published in the period from 01 July 2002 until 01
July 2010. The study investigates 22 very serious accidents and the 133 causal
factors identified as leading to them. It concludes that very serious
accidents, distinguish themselves by having causal factors that are to be found
higher up in organizations, in comparison to other accidents.”

The decision to
deploy a fragile and poorly understood platform for 18 months with almost no
consideration given to the cumulative risk is a real culprit here. Another is a
misapplied warship-staffing policy that pays too little attention to the
distinctive mission and needs of this type of ship. Better decision-making on
either of these matters would have reduced the chances of the flood happening. They would not have corrected the cultural issues, but they would
have eliminated crucial factors that enabled those to have such an amplified
effect.

In the end, no lives were lost on
Endurance, and the ship made it to port. There is no guarantee that any future
repeat of this type of incident will be as kind.

To Finish

Any analysis of
a disaster such as this inevitably tends toward the negative. It is an
appropriate counter-balance, therefore, to finish this three-part series by
going back to Part 1 and the heroic actions and deeds of the
ship’s company on that cold day in the South Pacific just over 10 years ago. The
ship was brilliant but flawed; the flood might have been inevitable or
avoidable – one can’t be absolutely sure. What I am absolutely certain of, is
that regardless of all the difficulties and shortcomings mentioned above, the
sailors onboard that day, from a standing start, conducted themselves with the
professionalism and courage that typifies the finest traditions of the Royal
Navy. No one underperformed and many performed exceptionally. Some were
rewarded for their efforts, others were not. Put yourself in a dark, oily and
violently rolling machinery space, with freezing water coming in at a rate of
2400 tons an hour making enough noise to drown out the main engines. A mayday
call goes out on the bridge and no-one answers. What would you do? The ship’s
company of HMS Endurance ran at it head-on until beaten out of the space, then
they ran at the next challenge and the next one, for 48 hours until we were
alongside. Because of that, the ship didn’t sink and no one died. Given how
this scenario could have played out, that’s all that really matters. Thanks
everyone.

Author BioOther Articles

Commander Tom G Sharpe OBE RN (Retd)

Tom Sharpe is a freelance communications consultant specialising in managing reputations and capacity building for complex and often contested organisations. Prior to this he spent 27 years in the Royal Navy, 20 of which were at sea. He commanded four different warships; Northern Ireland, Fishery Protection, a Type 23 Frigate and the Ice Patrol Vessel, HMS Endurance.